Geoff Bennett:
Health care costs are rising, putting new strain on millions of Americans and raising questions about what coverage they can afford. According to KFF — a health policy research organization — premiums for employer-sponsored family health insurance have increased 9 percent this year, with the average annual cost now exceeding $7,000 for workers.
And the challenges extend to Medicare Advantage, the private insurance plan that more than 30 million Americans choose as an alternative to traditional Medicare. With the annual Medicare open enrollment period now underway, seniors are weighing their options.
But in some parts of the country, insurers are withdrawing from the markets or eliminating plans that Americans have come to rely on. We spoke with several older people who are having difficulty adapting to these changes and to an increasingly complex health care system.
Susan Hayse, Medicare Advantage customer:
My name is Susan Hayse and I have been in Medicare Advantage for four years.
Bob Heffernan:
Medicare Beneficiary: My name is Bob Heffernan in Vermont and I was on the Medicare Advantage plan, actually two of them for three years, and when they both opted out of that system, I successfully went back to original Medicare.
Diane Payne, Medicare Advantage customer:
My name is Diane Payne. And my biggest challenge in choosing a plan next year is that the cost of dental and vision plans is increasing. Deductibles go down – out-of-pocket costs go up. And I just want to try to get the best deal for what I’m paying.
Bob Heffernan:
Medicare Advantage was truly superior, in my opinion, to original Medicare. It covered doctor visits, lab fees, prescription medications, hospitalization fees. And now I don’t have the option to go back to Medicare Advantage because they basically left the state of Vermont.
Diane Payne:
I realized last November that I had been diagnosed with breast cancer and an agent came to the house to talk to me. It was difficult to know what to do.
Susan Hayse:
That year, it was a big shock. Every year, you receive a notice from your insurance company informing you that changes will be made to your policies. There were things whose copies represented dollar amounts, like $50, rising to 50 percent.
Diane Payne:
I’ve seen that chronic illnesses and things like cancer can impact, even on our Advantage plans, how much you’re going to pay per call and office visit. Oh, I wish I knew what I could get myself into. Will I be charged more? Will I still be able to see my oncologist?
Susan Hayse:
I have developed a condition that will likely prevent me from being able to go back to original Medicare and a supplemental policy or it will cost me exorbitantly.
Bob Heffernan:
Now, of course, we are again forced to pay for Medigap, which is expensive, and to pay for prescription EI, which is expensive, and to pay for the eye doctor and the dentist.
Diane Payne:
Because of chemo and radiation, dental care has become very important to me. And if they just want to cover exams and not fillings or problems, and they removed it, my current plan, I started looking elsewhere.
Bob Heffernan:
They all have franchises now. So I’m not even adding that you pay until you reach a deductible, which you have to pay out of pocket before they even start covering.
Susan Hayse:
If I am unable to switch to Original Medicare and a supplemental plan due to a pre-existing condition, I will switch to another Advantage plan that more closely aligns with the medical network I prefer here in my area.
Diane Payne:
It’s groundwork for something that should be much simpler. Tell us. Just put it on your plan and just say what it will cost.
Geoff Bennett:
Lots to discuss.
Luckily, we have with us Dan Weissmann, creator and host of the healthcare podcast “An Arm and a Leg.”
It’s great talking with you.
So your team recently reviewed changes to Medicare Advantage. What did you find? What’s driving all these changes and, in some cases, insurance companies abandoning the plans seniors now rely on?
Dan Weissmann, host:
Yes. And there’s no single answer to that question, except for the most general answer, which is that insurance companies are private companies, they’re accountable to shareholders, and they’ve decided in many cases that the plans that we offer aren’t going to make us enough money, so we’re not going to offer them anymore, or we’re going to change the terms to be more beneficial to us and less beneficial to you.
Geoff Bennett:
And for people who haven’t yet used these programs, we should explain or you should explain, what is the difference between Medicare and Medicare Advantage?
Dan Weissmann:
Traditional Medicare, as it is called, is run by the federal government. It’s kind of what we call Medicare. Unless you go to the hospital or get something at the pharmacy counter, everything else, physical therapy, outpatient surgery, doctor visits, traditional health insurance only covers 80% of the bill.
So you’re responsible for 20 percent, which can be, listen to all these things I just said, untold thousands of dollars, depending on your health. And unlike other insurance these days, there is no maximum amount to pay. So you might have to pay for almost everything, unless you pay out of pocket for what’s called a supplemental plan or a Medigap plan.
And this fills that gap. However, there are still some things that traditional health insurance doesn’t cover at all, including vision, dental, and hearing. People sometimes joke that these are luxury organs?
So enter Medicare Advantage. It is managed by private insurance companies. And they will say: we will put all these things together. We’re going to give you vision, we’re going to give you dental care, we’re going to give you hearing. You will not be forced to pay untold amounts of money. We will limit these things for you.
And one thing that was a big surprise to a lot of people when I first started talking about this, it was a surprise to me, is that Medicare is not free. For that, you pay a premium of about $200 a month for most people in the federal government. Some Medicare Advantage plans are “we’ll take care of it for you.”
So it’s very, very attractive. Medicare Advantage has what some people think is a disadvantage, which is that you negotiate with a large insurance company for your health care and do it on their terms. They can tell you, no, this doctor is not in our network, we don’t pay for that. Or, yes, you say you want this treatment, it’s not in our plans. We’re not going to pay for that. You can fight us if you want.
So these are things that many of us who are under 65 imagine – we didn’t imagine that we would still be conflicted once we got to Medicare, but it’s part of Medicare Advantage.
Geoff Bennett:
For someone who decides that Medicare Advantage is no longer right for them, is it easy to go back to traditional Medicare? Are there any financial or coverage obstacles they couldn’t foresee?
Dan Weissmann:
Yes, it can be very difficult. In some ways, you have a choice between traditional Medicare and Medicare Advantage when you first sign up for Medicare, when you’re typically 65 years old.
And it’s generally a no-support situation, with the exception of a few states. When you first sign up for Medicare, you can get an additional plan if you want one later. If you want to go back to traditional Medicare, they may refuse to cover you, the supplemental plan, or a Medigap plan.
They may say you have a pre-existing condition, we don’t want to sell you a policy, or we’re going to price your policy to a price you can’t afford. This surprises a lot of people, and that’s one thing, because you sign up for Medicare at 65, you could be like the captain of the pickleball team, everything’s fine, never go to the doctor.
But you’re signing up for Medicare Advantage for an older, perhaps sicker, version of yourself. And it’s difficult for a lot of people.
Geoff Bennett:
As registrations open and the December 7 deadline approaches, what should seniors pay particular attention to? What is the most important advice you can offer?
Dan Weissmann:
The first is to monitor the mail. If you receive a letter from your insurance company saying we are changing your plan or no longer offering your plan, you want to get started immediately. And then you want to start evaluating your options.
There’s kind of two big places to go. The first is that Medicare itself operates a hotline. It’s like 1-800-MEDICARE. Call. The other is that every state has a program called SHIP.
It’s an acronym, but basically it’s a federally funded program that exists to help you understand your health insurance choices. Nobody earns commission. They are there to help you. And the best way to find your state’s is to go to Google and type in the name of your state, the word SHIP, and the word Medicare. And it should appear immediately.
You call these people and you want to do it as soon as possible. In addition to many plans closing this year, some carriers have asked and received permission from the federal government to cap enrollment in certain plans. So you might identify a plan and you’ll say, that’s the one I want. And they might say, if you’re late, sorry, there’s no room for you in this plan anymore. So you want to get started right away.
Geoff Bennett:
Dan Weissmann, creator and host of the “An Arm and a Leg” podcast, thanks for speaking with us.
Dan Weissmann:
Thank you very much for inviting me.
Gn bussni
